Invited Lecture by Nikhil Vasdev Venue - Scottish Prostate Cancer Symposium Location - Hilton Double Tree Spa Hotel, Dunblane, Scotland Date - 22/10/2013

1. Robotic prostatectomy –
the way forward or is the jury still out?
Mr Nikhil Vasdev
Post CCT Robotic Urological Fellow
(RCSEng/ BAUS National Accredited Fellowship programme)
Hertfordshire and South Bedfordshire Urological Cancer Centre
Lister Hospital
Stevenage
Dunblane-INVITE_Layout 1 05/09/2013 08:07 Page 1
Faculty in Robotic Urology
Chitra Sethia Robotic Centre
UCL
London
INVITATION
Prostate Cancer
Evening Symposium

2. Conflicts of Interest
! Nil
Financial disclosures
! Nil

3. Introduction
! Men with localized prostate cancer can be offered a radical
prostatectomy
! The types of prostatectomy being offered in the UK
!
!
!
!
Open radical prostatectomy (ORP)
Laparoscopic radical prostatectomy (LRP)
Robotic radical prostatectomy (RRP)
Perineal prostatectomy (RPP)

5. ! Baseline problems in finding evidence for superiority
! A Randomized clinical trial is not feasible because both expert
surgeons and patients have their bias regarding the optimal
technique
! No level 1 evidence
! Different definitions – Positive margins, biochemical recurrence,
urinary incontinence and sexual function
! Limited to single case series, systematic reviews and meta-analysi
! Selection bias in these studies often from high volume, academic
centers

7. Aim
! To evaluate the safety and efficacy of RRP in comparison to
ORP and LRP
RRP
LRP
ORP
Comparative effectiveness research (CER)

8. Aim of prostate cancer surgery
ORP / LRP
RRP
Trifecta
Pentafecta
Disease control
Disease control
Potency
Potency
Continence
Continence
Negative Margins
Complications

9. Objective criteria considered
! Cancer cure rates (In intermediate and high risk groups)
! Positive surgical margin rates
! Urinary continence
! Erectile dysfunction rates
! Peri-operative morbidity
! Post-operative complications
! Costs

10. Nature Reviews Urology 2004
Technology Insight: surgical robots
Expensive toys or the future of urologic
surgery?
‘‘A Robot Saved My Life’’: Is It a Myth?
Premature Robotic Surgery:
Putting Patients and Professionals
at Risk
Robotic Surgery: Hope or Hype?
Presidential Debate SAGES 2011
Will the Future of Health
Care Lead to the End of the
Robotic
Golden Years?

11. Robotic Surgery – Current trend
Robotic technology has been
adopted rapidly over the past 4
years in both the United States
and Europe.
The number of robot-assisted
procedures that are performed
worldwide has nearly tripled
since 2007, from 80,000 to
205,000.
Between 2007 and 2009, the
number of da Vinci
systems75%, from almost 800
to around 1400, and the
number that were installed in
other countries doubled, from
200 to nearly 400

12. da Vinci European Installed Base
1999 – 2012
®
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010-12

13. da Vinci USA Installed Base 1999 – 2012
®

14. Surgical Advantages of Robotic Surgery

15. Surgical Advantages of Robotic Surgery
10 X magnification

16. Surgical disadvantages of
robotic surgery
! Lack of haptic feedback
! Cost

17. Surgical disadvantages of
robotic surgery
! Positional injuries and anaesthetic/physiological
repercussions of the steep trendelenburgh position

18. rs). Unadjusted associaented in TABLE 2. Results
y consistent with adtions. In the propensityyses (TABLE 3), men unRP vs RRP experienced
h of stay (median, 2.0 vs
R, 0.67; 95% CI, 0.58ss likely to receive heterfusions (2.7% vs 20.8%;
CI, 0.06-0.17), and were
of postoperative respirations (4.3% vs 6.6%; OR,
I, 0.46-0.87), miscellal complications (4.3% vs
5; 95% CI, 0.56-0.99), and
tricture (5.8% vs 14.0%;
% CI, 0.28-0.52).
men undergoing MIRP vs
ced more genitourinary
(4.7% vs 2.1%; OR, 2.28;
3.22) and were more ofd as having incontinence
function (26.8 vs 19.2 per 100 personyears; OR, 1.4; 95% CI, 1.14-1.72). The
MIRP vs. ORP undergoing Surgery
Figure. Use of Minimally Invasive vs Open
Retropubic Radical Prostatectomy for Men
Diagnosed 2003-2007 in
as Having Prostate Cancer
Radical Prostatectomy, %
2002-2005 and Undergoing Surgery in
2003-2007
100
90
80
70
60
50
40
30
20
10
0
Radical prostatectomy
Minimally invasive
Retropubic
2003
No. of patients
244
Minimally
invasive
Retropubic 2394
usted Outcomes by Surgical Approach
2004
2005
2006-2007
(Combined)
Year of Surgery
542
843
309
2218
1881
406
Hu J et al, JAMA, 2009, Vol 302

19. Oncological Outcomes
! 13 years since the first robotic procedure
! Few centres have follow up of more than 5 years
! Current data indicates that the BCR-free survival estimates
!
!
!
!
95.1% at 1 year
90.6% at 3 years
86.6% at 5 years
81.0% at 7 years

20. Oncological Outcomes
! Badani et al, 7.2% PSA recurrence rate with a 5 year
actuarial biochemical free survival of 84% of this series
! Despite of differences , given the relative follow up for RRP
it is difficult to comment of the superiority of which
technique is better

21. Cancer Control - Selected large RPseries
Technique and series
No of
patients
pT2,%
Overall PSM,
%
BDFS,%
5 year
BDFS,%
10 year
10 year CSS,
%
Han et al
2404
51
11
92
85
96
Roehl et al
3478
61
80
68
97
Chun et al
4277
64.3
21.5
70
61
Guillonneau et al
1000
77.5
19.2
90(3yrs)
Stolzenberg et al
700
55.4
19.8
Lein et al
1000
70.2
26.8
Menon et al
2652
77.7
13
Mottrie et al
184
65.5
15.7
Patel et al
500
78
9.4
Sooriakumaran et al
944
74%
22%
Open RRP
Lap RP
RALP
87%
83%
98%

22. ! Silberstein compared early oncological outcomes of 961
ORP and 493 RRP
! This study is a convincing study, short of a randomised trial,
that suggests that in experienced hands both techniques can
be effective, and that surgeon experience had a stronger
effect than technique [Data from 4 high volume centres]
! RRP surgeons are five times more likely to omit pelvic LNDs
than open, even for high-risk cancers

23. Positive Surgical Margin
! The presence of a PSM has a significant effect on prostate
cancer progression
! The positive surgical margin rate was 20% for ORP versus
16.7% for RALRP in a study by Ahlering and coworkers
! Smith and colleagues retrospectively reviewed 200
procedures from each approach. The overall incidence of
positive surgical margins was significantly lower among the
RALRP cohort compared with ORP cases (15% vs 35%, P
< .001)

24. Relative effectiveness of robot-assisted and
standard laparoscopic prostatectomy as
alternatives to open radical prostatectomy
for treatment of localised prostate cancer:
a systematic review and mixed treatment
comparison meta-analysis
Clare Robertson, Andrew Close*, Cynthia Fraser, Tara Gurung, Xueli Jia,
Pawana Sharma, Luke Vale†, Craig Ramsay and Robert Pickard‡
Health Services Research Unit, University of Aberdeen, Aberdeen, *School of Biology, †Institute of Health and Society,
and ‡Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, UK
Re-use of this article is permitted in accordance with the Terms and Conditions set out at
http://wileyonlinelibrary.com/onlineopen#OnlineOpen_Terms
Objective
PSM
Robotic Prostatectomy
• To compare the effectiveness of robot-assisted and standard
laparoscopic prostatectomy.
Methods
17.6%
• A care pathway was described.
• We performed a systematic literature review based on a
search of Medline, Medline in Process, Embase, Biosis,
Science Citation Index, Cochrane Controlled Trials Register,
Current Controlled Trials, Clinical Trials, WHO
International Clinical Trials Registry and NIH Reporter, the
Resultslaparoscopic
PSM
Prostatectomy
• We included data from 19 064 men across one RCT and 57
non-randomised comparative reports.
• Robotic prostatectomy had a lower risk of major
intra-operative harms such as organ injury [0.4% robotic vs
2.9% laparoscopic], odds ratio ([OR] {95% credible interval
[CrI]} 0.16 [0.03 to 0.76]), and a lower rate of surgical
margins positive for cancer [17.6% robotic vs 23.6%
laparoscopic], OR [95% CrI] 0.69 [0.51 to 0.96]). There was
no evidence of a difference in the proportion of men with
urinary incontinence at 12 months (OR [95% CrI] 0.55 [0.09
to 2.84]). There were insufficient data on sexual dysfunction.
23.6%

25. New techniques to reduce PSM during
Robotic Prostatectomy
EUROPEAN UROLOGY 62 (2012) 333–340
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Surgery in Motion
Neurovascular Structure-adjacent Frozen-section Examination
(NeuroSAFE) Increases Nerve-sparing Frequency and Reduces
Positive Surgical Margins in Open and Robot-assisted
Laparoscopic Radical Prostatectomy: Experience After 11 069
Consecutive Patients
Thorsten Schlomm a,b,y,*, Pierre Tennstedt a,y, Caroline Huxhold a,y, Thomas Steuber a,
¨us
Georg Salomon a, Uwe Michl a, Hans Heinzer a, Jens Hansen a, Lars Buda a, Stefan Steurer c,
c
c
a
c
Corinna Wittmer , Sarah Minner , Alexander Haese , Guido Sauter , Markus Graefen a,
Hartwig Huland a

26. Nerve-sparing radical
ferenceoftheprostatetodeterminetheSMstatusofthecompleteneurovasculartissuecorresponding prostatic surface.
prostatectomy
NeuroSafe –Outcome measurements and statistical analysis:positiveNeuroSAFE on NS
technique to reduce The impact of
Surgery
surgical marginfrequency, SM status, and biochemical recurrence (BCR) was analyzed by chi-square
during Robotic Prostatectomy
Nerve-sparing
test, and by Kaplan-Meier analyses in propensity score–based matched cohorts.
Frozen section
Results and limitations: Positive SMs (PSMs) were detected in 1368 (25%) NeuroSAFE
RPs, leading to a secondary resection of the ipsilateral neurovascular tissue. Secondary
Surgical margin
wide resection resulted in conversion to a definitive negative SM (NSM) status in 1180
Propensity score
Please visit
www.europeanurology.com and
www.urosource.com to view the
accompanying video.
(86%) patients. In NeuroSAFE RPs, frequency of NS was significantly higher (all stages:
97%vs81%;pT2:99%vs92%;pT3a:94%vs72%;pT3b:88%vs40%;p< 0.0001)andPSM
ratesweresignificantlylower(allstages:15%vs22%;pT2:7%vs12%;pT3a:21%vs32%;
p< 0.0001) than in the matched non-NeuroSAFE RPs. In propensity score–based comparisons,NeuroSAFEhadnonegativeimpactonBCR(pT2,p= 0.06;pT3a,p= 0.17,pT3b,
p= 0.99), and BCR-free survival of patients with conversion to NSM did not differ
significantly from patients with primarily NSM (pT2, p = 0.16; pT3, p = 0.26).
y

27. Our experience with on-table frozen section
! N=14 patients
! Commenced procedure in
November 2012
! All patients were intermediate and
high risk
! All patients had intrafascial nerve
spares
! Our T2 positive margin rates are 0%
from 18%
! Our T3 positive margin rates are
17% from 28%
! Adds a mean of 17 minutes to
operative times

28. Intraoperative outcomes
! Duration of operative time is used as a marker of the
learning curve with RRP
! With time all series have a reduction in the operative times
and console times
! Operative times were shorter in the RRP when compared to
LRP
Operative times Robotic Prostatectomy
Operative times laparoscopic
Prostatectomy
170 +/- 34.2 min
235 +/- 49.9 min
p<0.001

29. Our experience

30. Intraoperative Blood loss
! Virtually all published reports confirm a reduction in blood
loss RRP
! The reason for reduced blood loss
! Pneumoperitoneum
! DVC dissection reserved till the end of procedure

31. DVC ligation and suturing

32. Late complications
Kowalczyk; EUROPEAN UROLOGY 61 (2012) 803–809
Complication
MIRP n=11108
RRP n=45227
P value
Anastomotic stricture
3%
9.3%
<0.001
Ureteral injury
0.5%
1.3%
<0.001
Recto-urethral fistula
0.4%
0.4%
0.999
Lymphocoele
1.3%
2.2%
<0.001
Surgery for incontinence
0.3%
0.3%
0.734

33. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Perioperative Outcomes
and Complications After Robot-assisted Radical Prostatectomy
Giacomo Novara a,*, Vincenzo Ficarra a,b, Raymond C. Rosen c, Walter Artibani d,
Anthony Costello e, James A. Eastham f, Markus Graefen g, Giorgio Guazzoni h,
Shahrokh F. Shariat i, Jens-Uwe Stolzenburg j, Hendrik Van Poppel k, Filiberto Zattoni a,
Francesco Montorsi l, Alexandre Mottrie b, Timothy G. Wilson m
• 110 papers evaluating oncologic outcomes following RARP
• Overall mean operative time is 152 min
a
University of Padua, Padua, Italy;
Watertown, MA, USA;
d
b
O.L.V. Robotic Surgery Institute, Aalst, Belgium;
Cancer Center, New York, NY, USA;
g
e
Department of Epidemiology, New England Research Institutes, Inc.,
f
Memorial Sloan-Kettering
Martini-Clinic, Prostate Cancer Centre, University Hamburg-Eppendorf, Hamburg, Germany;
h
University Vita-Salute San
• Mean blood loss is 166 ml
Raffaele, H. San Raffaele-Turro, Milan, Italy;
k
c
Royal Melbourne Hospital, Grattan Street, Melbourne, Australia;
University of Verona, Verona, Italy;
i
Weill Medical College of Cornell University, New York, NY, USA;
University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium;
l
j
University of Leipzig, Leipzig, Germany;
University Vita-Salute San Raffaele, H. San Raffaele, Milan, Italy;
m
City of Hope
National Cancer Center, Duarte, CA, USA
Abstract
• Article infotransfusion rate is 2%
Mean
Article history:
Accepted May 22, 2012
Published online ahead of
print on June 2, 2012
Context: Perioperative complications are a major surgical outcome for radical prostatectomy (RP).
Objective: Evaluate complication rates following robot-assisted RP (RARP), risk factors
for complications after RARP, and surgical techniques to improve complication rates
after RARP. We also performed a cumulative analysis of all studies comparing RARP with
retropubic RP (RRP) or laparoscopic RP (LRP) in terms of perioperative complications.
Evidence acquisition: A systematic review of the literature was performed in August
2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using
the term radical prostatectomy was applied. The following limits were used: humans;
gender (male); and publications dating from January 1, 2008. A cumulative analysis was
conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).
Evidence synthesis: We retrieved 110 papers evaluating oncologic outcomes following
RARP. Overall mean operative time is 152 min; mean blood loss is 166 ml; mean
transfusion rate is 2%; mean catheterization time is 6.3 d; and mean in-hospital stay
is 1.9 d. The mean complication rate was 9%, with most of the complications being of low
grade. Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are the
most prevalent surgical complications. Blood loss (weighted mean difference: 582.77;
• Mean catheterization time is 6.3 d
• Keywords: in-hospital stay is 1.9 d
Mean
Prostatic neoplasms
Prostatectomy
Laparoscopy
Robotics

34. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Perioperative Outcomes
and Complications After Robot-assisted Radical Prostatectomy
• Giacomo Novara *, Vincenzo rate was ,9%, with C. Rosen , the complications being of
The mean complication Ficarra Raymond most of Walter Artibani ,
Anthony Costello , James A. Eastham , Markus Graefen , Giorgio Guazzoni ,
low grade
Shahrokh F. Shariat , Jens-Uwe Stolzenburg , Hendrik Van Poppel , Filiberto Zattoni ,
a,
a,b
e
c
f
i
d
g
j
h
k
a
Francesco Montorsi l, Alexandre Mottrie b, Timothy G. Wilson m
• Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are
the most prevalent surgical complications
a
University of Padua, Padua, Italy;
Watertown, MA, USA;
d
b
O.L.V. Robotic Surgery Institute, Aalst, Belgium;
Cancer Center, New York, NY, USA;
g
k
Department of Epidemiology, New England Research Institutes, Inc.,
f
Memorial Sloan-Kettering
Martini-Clinic, Prostate Cancer Centre, University Hamburg-Eppendorf, Hamburg, Germany;
h
University Vita-Salute San
Raffaele, H. San Raffaele-Turro, Milan, Italy;
i
e
c
Royal Melbourne Hospital, Grattan Street, Melbourne, Australia;
University of Verona, Verona, Italy;
Weill Medical College of Cornell University, New York, NY, USA;
University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium;
l
j
University of Leipzig, Leipzig, Germany;
University Vita-Salute San Raffaele, H. San Raffaele, Milan, Italy;
m
City of Hope
National Cancer Center, Duarte, CA, USA
• Article infoloss (weighted mean difference: 582.77; p < 0.00001) and transfusion rate
Blood
Abstract
(odds ratio [OR]: 7.55; p < 0.00001) were lower in RARP than in RRP, whereas
Context: Perioperative complications are a major surgical outcome for radical prostaArticle history:
Accepted May 22, 2012
only transfusion rate (OR:tectomy (RP). = 0.005) was lower in robot-assisted RP (RARP),LRP
2.56; Evaluate complication rates following RARP than in risk factors
Objective: p
Published online ahead of
print on June 2, 2012
for complications after RARP, and surgical techniques to improve complication rates
after RARP. We also performed a cumulative analysis of all studies comparing RARP with
retropubic RP (RRP) or laparoscopic RP (LRP) in terms of perioperative complications.
Evidence acquisition: A systematic review of the literature was performed in August
2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using
the term radical prostatectomy was applied. The following limits were used: humans;
gender (male); and publications dating from January 1, 2008. A cumulative analysis was
conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK).
Evidence synthesis: We retrieved 110 papers evaluating oncologic outcomes following
RARP. Overall mean operative time is 152 min; mean blood loss is 166 ml; mean
transfusion rate is 2%; mean catheterization time is 6.3 d; and mean in-hospital stay
is 1.9 d. The mean complication rate was 9%, with most of the complications being of low
grade. Lymphocele/lymphorrea (3.1%), urine leak (1.8%), and reoperation (1.6%) are the
most prevalent surgical complications. Blood loss (weighted mean difference: 582.77;
• Keywords: can be performed routinely with a relatively small risk of complications.
RARP
Prostatic neoplasms
Prostatectomy experience, clinical patient characteristics, and cancer characteristics
Surgical
Laparoscopy
Robotics affect the risk of complications
may

35. Continence
EUROPEAN UROLOGY 62 (2012) 405–417
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting
Urinary Continence Recovery After Robot-assisted Radical
Prostatectomy
Vincenzo Ficarra a,b,*, Giacomo Novara a, Raymond C. Rosen c, Walter Artibani d,
Peter R. Carroll e, Anthony Costello f, Mani Menon g, Francesco Montorsi h, Vipul R. Patel i,
Jens-Uwe Stolzenburg j, Henk Van der Poel k, Timothy G. Wilson l, Filiberto Zattoni a,
Alexandre Mottrie b
a
University of Padua, Padua, Italy;
Verona, Italy;
h
e
b
O.L.V. Clinic, Aalst, Belgium;
c
New England Research Institutes, Inc., Watertown, MA, USA;
University of California, San Francisco, CA, USA; f Royal Melbourne Hospital, Melbourne, Australia;
g
d
University of Verona,
Henry Ford Hospital, Detroit, MI, USA;
Vita-Salute San Raffaele University, Milan, Italy; i Global Robotic Institute, Florida Hospital Celebration Health, Orlando, FL, USA; j University of Leipzig,
Leipzig, Germany;
Article info
k
Netherlands Cancer Institute, Amsterdam, The Netherlands; l City of Hope Cancer Center, Duarte, CA, USA
Abstract

36. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting
Urinary Continence Recovery After Robot-assisted Radical
Prostatectomy
Vincenzo Ficarra a,b,*, Giacomo Novara a, Raymond C. Rosen c, Walter Artibani d,
Peter R. Carroll e, Anthony Costello f, Mani Menon g, Francesco Montorsi h, Vipul R. Patel i,
Jens-Uwe Stolzenburg j, Henk Van der Poel k, Timothy G. Wilson l, Filiberto Zattoni a,
Alexandre Mottrie b
• 51 articles reporting urinary continence rates after RARP
• The 12-mo urinary incontinence rates ranged from 4% to 31%, with a
mean value of 16% using a no pad definition.
• Posterior musculofascial reconstruction with or without anterior
reconstruction was associated with a small advantage in urinary
continence recovery 1 mo after RARP.
• Only complete reconstruction was associated with a significant
advantage in urinary continence 3 mo after RARP (odds ratio [OR]:
0.76; p=0.04)
• Cumulative analyses showed a better 12-mo urinary continence recovery
after RARP in comparison with RRP (OR: 1.53; p=0.03) or LRP (OR:
2.39; p=0.006)
a
University of Padua, Padua, Italy;
Verona, Italy;
h
e
b
O.L.V. Clinic, Aalst, Belgium;
University of California, San Francisco, CA, USA;
Vita-Salute San Raffaele University, Milan, Italy;
Leipzig, Germany;
k
i
f
c
New England Research Institutes, Inc., Watertown, MA, USA;
Royal Melbourne Hospital, Melbourne, Australia;
g
d
Global Robotic Institute, Florida Hospital Celebration Health, Orlando, FL, USA;
Netherlands Cancer Institute, Amsterdam, The Netherlands;
l
University of Veron
Henry Ford Hospital, Detroit, MI, US
j
University of Leipz
City of Hope Cancer Center, Duarte, CA, USA
Article info
Abstract
Article history:
Accepted May 22, 2012
Published online ahead of
print on May 31, 2012
Context: Robot-assisted radical prostatectomy (RARP) was proposed to improve fun
tional outcomes in comparison with retropubic radical prostatectomy (RRP) or lapar
scopic radical prostatectomy (LRP). In the initial RARP series, 12-mo urinary continen
recovery rates ranged from 84% to 97%. However, the few available studies comparing RAR
with RRP or LRP published before 2008 did not permit any definitive conclusions about th
superiority of any one of these techniques in terms of urinary continence recovery.
Objective: The aims of this systematic review were (1) to evaluate the prevalence an
risk factors for urinary incontinence after RARP, (2) to identify surgical techniqu
able to improve urinary continence recovery after RARP, and (3) to perform a cumulativ
analysis of all available studies comparing RARP versus RRP or LRP in terms of th
urinary continence recovery rate.
Evidence acquisition: A literature search was performed in August 2011 using th
Medline, Embase, and Web of Science databases. The Medline search included only
free-text protocol using the term radical prostatectomy across the title and abstract fiel
of the records. The following limits were used: humans; gender (male); and publicatio
date from January 1, 2008. Searches of the Embase and Web of Science databases use
the same free-text protocol, keywords, and search period. Only comparative studies
clinical series including >100 cases reporting urinary continence outcomes we
included in this review. Cumulative analysis was conducted using the Review Manag
v.4.2 software designed for composing Cochrane Reviews (Cochrane Collaboratio
Oxford, UK).
Evidence synthesis: We analyzed 51 articles reporting urinary continence rates aft
RARP: 17 case series, 17 studies comparing different techniques in the context of RAR
Keywords:
Prostatic neoplasms
Prostatectomy
Laparoscopy
Robotics
Please visit
www.eu-acme.org/
europeanurology to read and
answer questions on-line.

37. Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting
Urinary Continence Recovery After Robot-assisted Radical
Prostatectomy
*, Giacomo Novara , Raymond
Vincenzo Ficarra
Peter R. Carroll , Anthony Costello , Mani Menon , C. Rosen , Walter Artibani , R. Patel ,
Francesco Montorsi , Vipul
Jens-Uweprevalence Henk Van der Poel , Timothy G. after RARP isZattoni ,
Stolzenburg , of urinary incontinence Wilson , Filiberto influenced
• The Mottrie
Alexandre
by preoperative patient characteristics, surgeon experience,
surgical technique, and methods used to collect and report data
a,b,
a
e
c
f
d
g
j
k
h
i
l
a
b
a
University of Padua, Padua, Italy;
Verona, Italy;
h
e
b
O.L.V. Clinic, Aalst, Belgium;
University of California, San Francisco, CA, USA;
Vita-Salute San Raffaele University, Milan, Italy;
Leipzig, Germany;
k
i
f
c
New England Research Institutes, Inc., Watertown, MA, USA;
Royal Melbourne Hospital, Melbourne, Australia;
d
l
University of Veron
Henry Ford Hospital, Detroit, MI, US
Global Robotic Institute, Florida Hospital Celebration Health, Orlando, FL, USA;
Netherlands Cancer Institute, Amsterdam, The Netherlands;
Article info
g
j
University of Leipz
City of Hope Cancer Center, Duarte, CA, USA
Abstract
• Posterior musculofascial reconstruction seems to offer a slight
advantage in terms of 1-mo urinary continence recovery
Article history:
Accepted May 22, 2012
Published online ahead of
print on May 31, 2012
Keywords:
Prostatic neoplasms
Prostatectomy
Laparoscopy
Robotics
Context: Robot-assisted radical prostatectomy (RARP) was proposed to improve fun
tional outcomes in comparison with retropubic radical prostatectomy (RRP) or lapar
scopic radical prostatectomy (LRP). In the initial RARP series, 12-mo urinary continen
recovery rates ranged from 84% to 97%. However, the few available studies comparing RAR
with RRP or LRP published before 2008 did not permit any definitive conclusions about th
superiority of any one of these techniques in terms of urinary continence recovery.
Objective: The aims of this systematic review were (1) to evaluate the prevalence an
risk factors for urinary incontinence after RARP, (2) to identify surgical techniqu
able to improve urinary continence recovery after RARP, and (3) to perform a cumulativ
analysis of all available studies comparing RARP versus RRP or LRP in terms of th
urinary continence recovery rate.
Evidence acquisition: A literature search was performed in August 2011 using th
Medline, Embase, and Web of Science databases. The Medline search included only
free-text protocol using the term radical prostatectomy across the title and abstract fiel
of the records. The following limits were used: humans; gender (male); and publicatio
date from January 1, 2008. Searches of the Embase and Web of Science databases use
the same free-text protocol, keywords, and search period. Only comparative studies
clinical series including >100 cases reporting urinary continence outcomes we
included in this review. Cumulative analysis was conducted using the Review Manag
v.4.2 software designed for composing Cochrane Reviews (Cochrane Collaboratio
Oxford, UK).
Evidence synthesis: We analyzed 51 articles reporting urinary continence rates aft
RARP: 17 case series, 17 studies comparing different techniques in the context of RAR
• Update of a previous systematic review of literature shows, for the
first time, a statistically significant advantage in favor of RARP in
comparison with both RRP and LRP in terms of 12-mo urinary
continence recovery
Please visit
www.eu-acme.org/
europeanurology to read and
answer questions on-line.

38. Cost

39. Cost

40. Cost

41. Intuitive sales

42. What makes robotic surgery expensive ?
! The initial cost is extremely high, estimated to be about $1.8
million and the maintenance costs
! After ten uses of a robot, the instruments must be replaced
! Use of the robot comes with a slower learning curve for doctors.
! When hospitals attempt to balance patient safety with the high
training costs, sometimes poor patient outcomes occur.
! There are also increased costs to the patient per surgery, estimated
at around $2,500 per procedure compared to traditional methods

43. Robotic prostatectomy will always be more costly to the NHS because of the fixed
capital and maintenance charges for the robotic system
Our modelling showed that this excess cost can be reduced if capital costs of equipment
are minimised and by maintaining a high case volume for each robotic system of at least
100–150 procedures per year. This finding was primarily driven by a difference in
positive margin rate

44. How can we improve robotic
surgical outcomes
! Regulation of Training

45. How can we improve robotic
surgical outcomes
! Simulation
! Simulation and Technology enhanced Learning Initiative
(STeLI) project
! SAGES / RAST (Robotic assisted surgical training) programme
! Formal Fellowship training
! 6 robotic fellowships in the UK
! Only one recognized by the RCS/BAUS
! Strict audit of outcomes

46. Latest developments
! Robotic image integration surgery (Imris medical)

47. Latest Developments
! Haptic Feedback

48. Latest Developments

49. Robotic ProstatectomyIs the jury out ?

50. Conclusion
! Men undergoing a Robotic Prostatectomy appear to have :Lower intraoperative blood loss
Reduced surgical morbidity
Lower risk of a positive margin
Reduced risk of cancer recurrence and hence need to further
treatment
! Oncological outcomes are equivalent
! No evidence that men undergoing a RRP are disadvantaged in
terms of functional outcomes
! Longer follow up is required to relative effectiveness
!
!
!
!

51. Conclusion
“The Surgeon is the most important determinant of robotic
radical prostatectomy outcomes of peri-operative
complications, length of stay and strictures”
L Klotz
“The aim now should be to evaluate the cost of robotic
prostatectomy results in long term gain for patient”
J Meeks

52. Correspondence
! Mr Nikhil Vasdev
Post CCT Robotic Urological Fellow
(RCSEng/BAUS National Accredited Fellowship Programme)
Hertfordshire and South Bedfordshire Urological Cancer Centre
Lister Hospital
Stevenage
UK
Email –
nikhilvasdev@doctors.org.uk
Website – www.roboticsinsurgery.org